Endoscopic surgical systems and methods

ABSTRACT

An access system is provided for establishing an access path to a surgical site within a patient. The access system comprises an access portal defining a working channel with a central axis, and an adaptor with a mating section mountable to the access portal. The adaptor is selectively rotatable about the central axis. The access portal includes a plurality of openings and the adaptor includes a plurality of projections, each of the projections and openings being arranged so that, in a first orientation, the openings and projections align to allow mounting of the adaptor to the access portal and, in a second orientation, the openings and projections do not align to prevent disassociation between the adaptor and the access portal. The adaptor also includes a holder for a viewing device, the viewing device being movable with the adaptor about the access portal and vertically translatable relative to the access portal.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/966,699, filed on Apr. 30, 2018, which is a continuation of U.S.patent application Ser. No. 15/704,489, filed on Sep. 14, 2017, which isa continuation of U.S. patent application Ser. No. 14/640,608, filed onMar. 6, 2015, which claims the benefit of the filing date of U.S.Provisional Application No. 61/951,183, filed Mar. 11, 2014, thedisclosures of which are hereby incorporated by reference herein.

BACKGROUND OF THE INVENTION

The present invention relates to endoscopic surgical systems andmethods, and particularly to minimally-invasive access systems used withendoscopic tools and viewing devices to conduct surgical procedures on apatient (for instance, on the patient's spine).

Common degenerative spinal diseases, such as chronic degeneration of anintervertebral disc of the spine, may result in substantial pain anddiscomfort for a patient. Frequently, diseases of this type need to betreated through surgical intervention, which may include replacing theaffected disc(s) and potentially fusing the associated vertebrae throughthe use of an implant or other like device. In particular applications,adjacent vertebral bodies may be fused via an implant, through screwarrangements, and/or by using bone graft material to secure thevertebrae in a fixed state. Exemplary indications for such devicesinclude, but are not limited to, spinal stenosis, degenerative discdisease with a loss of disc height, disc herniation, spondylolisthesis,retrolisthesis, and discogenic back pain.

In replacing a diseased intervertebral disc(s) and effecting fusion, itis necessary to gain access to the disc space to conduct the surgicalprocedure. Increasingly, access is provided in a minimally-invasivemanner, such as through expandable or non-expandable access portals(e.g., retractors or cannula, which provide access to the disc spacethrough the skin and tissue of the patient). The benefits of aminimally-invasive procedure include, for example, less trauma to thepatient, as well as improved procedure and recovery times. In conductinga minimally-invasive surgical procedure, however, it is important forthe surgeon to maintain good visualization of the working area (e.g.,the space within the patient where the surgeon is performing theprocedure). Endoscopic tools and devices have been developed for usewith minimally-invasive access portals to allow visualization of theworking area. As an example, a surgeon might have the option ofconducting a minimally-invasive procedure through a retractor or acannula, while viewing the procedure via an endoscope inserted throughthe retractor or cannula. In this way, the surgeon is able to visualizethe working area (e.g., the intervertebral disc(s)) so that theoperation can be performed with more precision and confidence.

Although endoscopic devices and methods have been developed to enable asurgeon to conduct minimally-invasive or other surgical procedures withimproved visualization of the working area, such endoscopic devices arefrequently difficult and/or cumbersome to use. Improvements upon suchdevices and methods are therefore needed.

BRIEF SUMMARY OF THE INVENTION

A first aspect of the present invention includes an access system forproviding an access path to a surgical site within a patient. The accesssystem comprises an access portal defining a working channel with acentral axis, the access portal having at least one opening, and anadaptor with a mating section mountable to the access portal, such thatthe adaptor is selectively rotatable about the central axis, the adaptorhaving at least one projection movable through the at least one openingin the access portal to mate the adaptor to the access portal, whereinthe adaptor includes a holder for holding a viewing device. In someembodiments of this first aspect, the holder extends proximally above aproximal end of the access portal and includes a first aperture with anaxis that is aligned with the working channel of the access portal, thefirst aperture being configured to receive a mounting portion of theviewing device. In other embodiments, the access portal includes firstand second flanges spaced apart from one another to define a channel,the first flange including the at least one opening in the accessportal.

A second aspect of the invention comprises an access system forproviding an access path to a surgical site within a patient, the systemcomprising an access portal defining a working channel with a centralaxis, and an adaptor with a mating section mountable to the accessportal, such that the adaptor is selectively rotatable about the centralaxis, wherein the access portal includes a plurality of openings and theadaptor includes a plurality of projections, each of the projections andopenings being arranged so that, in a first orientation, the openingsand projections align with one another to allow mounting of the adaptorto the access portal and, in a second orientation, the openings andprojections do not align to prevent disassociation between the adaptorand the access portal, the adaptor including a holder for holding aviewing device. In an embodiment of this second aspect, when theopenings of the access portal and the projections of the adaptor arealigned, in the first orientation, each projection is movable through arespective one of the plurality of openings. In another embodiment, theaccess portal includes a first flange and the projections of the adaptorare arrangeable under the first flange after being moved through theopenings of the access portal.

A third aspect of the invention includes an access system for providingan access path to a surgical site within a patient, the systemcomprising an access portal defining a working channel with a centralaxis, and an adaptor with a mating section mountable to the accessportal, such that the adaptor is selectively rotatable about the centralaxis, wherein the access portal includes at least one opening and theadaptor includes at least one projection, the at least one projectionand opening being arranged so that, in a first orientation, the openingand projection align with one another and, in a second orientation, theopening and projection do not align, the adaptor including a holder forholding a viewing device. The holder may extend proximally above theproximal end of the access portal in this third aspect, and include afirst aperture with an axis that is aligned with the working channel ofthe access portal, the first aperture being configured to receive amounting portion of the viewing device. In some cases, the mountingportion of the viewing device is not rotatable within the firstaperture.

BRIEF DESCRIPTION OF THE DRAWINGS

A more complete appreciation of the subject matter of the presentinvention(s) and of the various advantages thereof can be realized byreference to the following detailed description in which reference ismade to the accompanying drawings in which:

FIG. 1A is a side view of an endoscopic access system according to oneembodiment of the present invention.

FIG. 1B is a top perspective view of FIG. 1A without the endoscopicviewing device shown.

FIG. 2A is a top perspective view of the access portal used in thesystem of FIGS. 1A-B.

FIG. 2B is a top perspective view of an adaptor used to mount anendoscopic viewing device to the access portal of FIG. 2A.

FIG. 2C is a side view showing the adaptor of FIG. 2B being insertedonto the access portal of FIG. 2A.

FIGS. 3A-B are top views showing the adaptor of FIG. 2B being rotated toengage the access portal of FIG. 2A.

FIG. 3C is a top perspective view of an endoscopic viewing deviceinserted into the adaptor and access portal of FIGS. 3A-B.

FIG. 4A is a side view of an access portal, an endoscopic viewingdevice, and an adaptor for holding the endoscopic viewing device,according to an embodiment of the present invention.

FIGS. 4B-C are cross-sectional views of the access portal, endoscopicviewing device, and adaptor shown in FIG. 4A.

DETAILED DESCRIPTION

In describing the preferred embodiments of the invention(s) illustratedand to be described with respect to the drawings, specific terminologywill be used for the sake of clarity. However, the invention(s) is notintended to be limited to any specific terms used herein, and it is tobe understood that each specific term includes all technicalequivalents, which operate in a similar manner to accomplish a similarpurpose.

Referring to FIGS. 1A-B, an exemplary access system 10 is shown. Accesssystem 10 is shown as a pedicle-based retraction system. Although accesssystem 10 is depicted in the context of a pedicle-based retractionsystem, the methods and devices set forth herein could, of course, beused with many different types of access systems, including those thatdo not anchor to bone. Such alternate systems are described in moredetail below.

Access system 10 is an endoscopic system that includes an access portal40, in this case a cannula, an adaptor 70 attached to access portal 40,and an endoscopic viewing device 100 mounted to adaptor 70 for viewing asurgical procedure conducted within or through access portal 40. Asurgeon can utilize access system 10 to more easily gain a clear imageof the working area for a surgical procedure such as, for example, aworking area adjacent the spine of a patient. In the case of FIGS. 1A-B,the working area is an intervertebral disc space 20 between adjacentvertebrae 21, 25. Access system 10 therefore provides a multitude ofbenefits to surgeons, due at least to its improved functionality andease of use, as set forth in detail below.

Access system 10 includes a frame 26 attached to separate arms 30, 32(while only two arms 30, 32 are shown, more than two arms can beutilized). A portion of frame 26 includes a bar 34. Arms 30, 32 extendfrom bar 34 and at least arm 30 (and optionally both arms 30, 32) ismovable along bar 34. Arm 30 can be fixed in any location relative tobar 34. Anchoring pins 22, 24 are attached to an end of arms 30, 32 viaa clamp mechanism or through other means, and are vertically slidablewithin the clamp. While arm 32 is fixed relative to bar 34, in oneembodiment, it may be rotated about its long axis to rotate theorientation of pin 24.

A clamp is also provided with access system 10 for connecting to accessportal 40 to maintain portal 40 in a stable position inside a patient.The clamp can engage access portal 40 and, in one embodiment, is movablealong with access portal 40 relative to access system 10. Indeed, accessportal 40 may be moved relative to access system 10 in a lateraldirection, or towards and away from access system 10. Thus, accesssystem 10 is dynamic in that it allows for movement of anchoring pins22, 24 via their connected arms 30, 32 and/or movement of access portal40 by way of its clamp and associated structures.

Access portal 40 is shown in detail in FIG. 2A. In some embodiments,access portal 40 is a cylindrical cannula, although it may be any othershape, such as triangular, trapezoidal, hexagonal, or diamond shaped. Itis also contemplated that access portal 40 may be an expandablestructure (e.g., a retractor with movable blades or an expandablecannula) or a cannula with a fixed dimension that is tapered in adirection extending towards its distal end or in a direction extendingtowards its proximal end (e.g., conical). Access portal 40 is capable ofproviding a minimally-invasive working channel 56 through the skin andtissue of a patient and, in one embodiment, it includes distal andproximal sections 42, 44 that are tubular in shape. Distal and proximalsections 42, 44 of access portal 40 cooperate together to define theextent of working channel 56. In the depicted embodiment, there is astep 45 on an inner surface of access portal 40 at the intersection ofdistal and proximal sections 42, 44, such that working channel 56 islarger at proximal section 44 as compared to distal section 42. Asreflected in FIGS. 3A-B, in some cases working channel 56 may be oval,but in other cases working channel 56 may be circular or any other shapethat facilitates access to the surgical site within the patient. An ovalshape provides a greater working volume along its major diameter ascompared to a circular shape, thus allowing the surgeon more room towork with along an axis coinciding with the major diameter.

Referring still to FIG. 2A, proximal section 44 of access portal 40 alsoincludes structure for engaging with an adaptor 70 that houses anendoscopic viewing device 100. In a particular embodiment, the structurecomprises first and second flanges 46, 48 extending from proximalsection 44 of access portal 40, with the first flange 46 having a seriesof spaced-apart openings 52. Flanges 46, 48 extend circumferentiallyabout proximal section 44 of access portal 40 and define a channel 50for mating with a portion of adaptor 70, as shown in FIG. 2C. Flange 48of access portal 40 does not include spaced-apart openings and rather iscontinuous or substantially continuous about proximal section 44 ofportal 40.

Adaptor 70 is shown in FIG. 2B and includes a mating section 72 that, inone embodiment, is circular and defines an opening 71. Mating section 72may also be semi-circular or any shape that can accommodate or attachwith proximal section 44 of access portal 40. Extending inward frommating section 72 are a number of projections 74 that are sized to passthrough spaced-apart openings 52 of flange 46 of access portal 40. Inparticular, the diameter of mating section 72 of adaptor 70 may beroughly equal to or slightly greater than the diameter of flange 46 ofaccess portal 40, and projections 74 of mating section 72 may extendinwardly so as to be slidable through spaced-apart openings 52 of flange46 of access portal 40. However, projections 74 and/or the diameter ofmating section 72 of adaptor 70 may be sized so that neither can travelpast flange 48 of access portal 40 (e.g., because the diameter of flange48 is larger than that of mating section 72 and/or an opening throughadaptor 70 defined by projections 74). For instance, due to theinwardly-projecting nature of projections 74, adaptor 70 may not be ableto travel past flange 48 of access portal 40 (e.g., due to interferencebetween projections 74 and flange 48). In one embodiment, four (4)projections 74 are present on mating section 72 of adaptor 70, althoughmore or less projections 74 are contemplated.

Adaptor 70 also includes a post 76 at an end of mating section 72, asshown in FIG. 2C. Post 76 extends upwards from mating section 72 to ascope holder 78 spaced apart from mating section 72. Scope holder 78 inturn extends towards a center of opening 71 defined by mating section 72so that an aperture 80 formed through scope holder 78 is aligned withopening 71. As shown in FIGS. 3A-B, scope aperture 80 is offset from thecenter of opening 71 through adaptor 70, although it is contemplatedthat scope aperture 80 may be positioned at the center of opening 71depending on the length of scope holder 78. Scope aperture 80, in oneembodiment, is oblong so as to mate with a correspondingly-shapedsection of an endoscopic viewing device 100, as described in subsequentsections.

As shown best in FIGS. 3A-B and 4C, scope adaptor 70 also includes anopening 84 extending through mating section 72 for receiving a screw orpin 82. Screw 82 may have external threads that mate with internalthreads formed in opening 84 so that screw 82 can be rotated to movescrew 82 into or out of opening 84 and ultimately in or out of contactwith access portal 40. A knob 83 is provided on screw 82 for thispurpose. Screwing screw 82 into and out of opening 84 in adaptor 70causes adaptor 70 to be fixed or movable in relation to access portal40, thus allowing the surgeon to fix or move the location of endoscopicviewing device 100. In particular, screwing screw 82 into opening 84 asufficient distance causes screw 82 to bear on access portal 40 and, dueto the friction between screw 82 and access portal 40, fix adaptor 70 inplace. Screwing screw 82 out of opening 84 causes it to disengage withaccess portal 40 and allow movement of adaptor 70 about access portal40.

FIGS. 2B and 4B depict another opening 88 formed through adaptor 70, inparticular its scope holding section 78, for receiving a screw or pin86. Opening 88, as shown in cross-section in FIG. 4B, extends throughscope holder 78 and communicates with scope aperture 80. Internalthreads may be formed within opening 88 to mate with external threads onscrew 86 so that screw 86 can be rotated within opening 88, therebycausing movement of screw 86 into and out of opening 88. Screw 86 mayinclude a knob 87 for facilitating its rotation. As described in moredetail below, screw 86 may be screwed within opening 88 to contactendoscopic viewing device 100 and fix its location in a verticaldirection, or it may be unscrewed from opening 88 to allow movement ofendoscopic viewing device 100 in a vertical direction.

FIG. 2C depicts scope adaptor 70 being attached to access portal 40 viapositioning mating section 72 of adaptor 70 over flange 46 of accessportal 40. In particular, projections 74 of adaptor 70 are aligned withspaced-apart openings 52 through flange 46 of access portal 40 and movedthrough openings 52 so that projections 74 lie within channel 50 formedbetween flanges 46, 48. In this orientation, projections 74 and/or abottom surface of mating section 72 of adaptor 70 may lie against asection of flange 48 so that adaptor 70 does not move axially beyond theextent of flange 48. With projections 74 arranged in channel 50 betweenflanges 46, 48, adaptor 70 may be rotated as shown in FIGS. 3A-B to anumber of different orientations for positioning scope holder 78circumferentially around access portal 40 and preventing movement ofadaptor 70 vertically away from proximal section 44 of access portal 40.For example, as shown in FIG. 3A, adaptor 70 may be arranged in anorientation in which projections 74 are aligned with spaced-apartopenings 52 (e.g., during placement of adaptor 70 onto access portal 40)and then, as shown in FIG. 3B, adaptor 70 may be rotated so thatprojections 74 are at least partially out of phase or not aligned withspaced-apart openings 52. In this way, projections 74 are disposed inchannel 50 of access portal 40 and certain sections 54 of flange 46 thatdo not include spaced-apart openings 52 overlie projections 74 so thatadaptor 70 is locked in an axially-fixed position (e.g., adaptor 70cannot disengage from access portal 40 when rotated to a position suchas that shown in FIG. 3B).

Adaptor 70 may be rotated three-hundred and sixty degrees (360°) aboutproximal section 44 of access portal 40 to position scope holder 78around proximal section 44. In addition, scope aperture 80 is, in oneembodiment, arranged offset from a center of mating section 72 ofadaptor 70 (and thus off-center in relation to working channel 56 ofaccess portal 40) so that scope aperture 80 is positioned at variouseccentric positions when adaptor 70 is rotated about proximal section 44of access portal 40. To fix adaptor 70 in a particular rotated position,a user may utilize screw 82. Screw 82, as reflected in FIG. 4C, may bescrewed into opening 84 until it contacts a surface of access portal 40arranged in channel 50 between flanges 46, 48, thus fixing adaptor 70rotationally with respect to access portal 40 (e.g., by way of frictioncreated between screw 82 and access portal 40). A surgeon can therefore,at his/her election, rotate adaptor 70 and fix scope holder 78 atvarious different locations about working channel 56 of access portal40. If in a particular step of the surgical procedure the surgeon doesnot require endoscopic visualization of the working area, the surgeoncan also always disengage adaptor 70 from access portal 40 by rotatingit so that projections 74 are again aligned with spaced-apart openings52, which allows the surgeon to vertically lift the adaptor 70 away fromaccess portal 40 by moving projections 74 through openings 52.

Referring now to FIGS. 4A-C, an endoscopic viewing device 100 isprovided with access system 10. Endoscopic viewing device 100 may be anyrigid or flexible/steerable endoscope known in the art at present, whichis insertable into scope holder 78 of adaptor 70. Viewing device 100includes a mounting section 102 with a geometry that matches thegeometry of scope aperture 80 through scope holder 78 (e.g., an oblonggeometry). In some cases, the geometries of mounting section 102 andscope aperture 80 through scope holder 78 can be selected to preventrotation of viewing device 100 relative to adaptor 70 once mountingsection 102 of viewing device 100 is situated within scope aperture 80(as in the depicted design), but it is equally contemplated that othergeometries may be used to allow rotation of viewing device 100 relativeto adaptor 70 (e.g., circular or hexagonal geometries or the like thatallow continuous or incremental rotation of viewing device 100 withinaperture 80 of adaptor 70). Endoscopic viewing device 100 also includesan eyepiece 108 and a viewing lens 106 for viewing the working area atthe surgical site. Viewing device 100 may also be connected to a monitoror other device so that the surgeon can easily see what is in the fieldof view of lens 106 of viewing device 100.

Referring still to FIGS. 4A-C, screw 86 extends through opening 88 inadaptor 70, in particular its post 76, to contact mounting section 102of endoscopic viewing device 100 so that viewing device 100 may beadjusted in a vertical direction according to the surgeon's preference.Mounting section 102 of viewing device 100 is elongated so that, as ittravels within scope aperture 80 of adaptor 70, mounting section 102stays in contact with the sides of scope aperture 80 (e.g., to preventviewing device 100 from rotating and to keep the geometries of mountingsection 102 and scope aperture 80 meshed with one another). Due to itselongated nature, mounting section 102 can therefore travel axiallywithin scope aperture 80 of adaptor 70 to move the position of lens 106of viewing device 100 distally or proximally. Mounting section 102 canbe any predetermined length to allow a particular amount of axialmovement of lens 106. In addition, a portion of viewing device 100 maybe of a greater dimension than scope aperture 80 of adaptor 70 so thatdistal movement of lens 106 past a certain point is restricted. Forinstance, a surface 110 on viewing device 100 may contact with adaptor70, as shown in FIG. 4B, to prevent further distal movement of lens 106past a predetermined point.

When the surgeon has positioned lens 106 at a desired location, screw 86can be screwed into opening 88 in post 76 of adaptor 70 to fix mountingsection 102 of viewing device 100 (and thus lens 106) at the desiredposition. In this manner, lens 106 may be adjusted both distally andproximally through scope aperture 80, and lens 106 may also be rotatedcircumferentially about access portal 40 via the movement of adaptor 70about access portal 40, as detailed above. Thus, the surgeon is providedwith a viewing device 100 that is movable to many different locations toalter the field of view for the surgeon at the working area. Theoperation can therefore proceed more efficiently and with bettervisualization of the surgical site. In addition, the surgeon can adjustthe positioning of viewing device 100 vertically or circumferentiallyabout access portal 40 so that, depending on the particular action beingtaken in the procedure, the best visualization of the surgical site isobtained.

A method of utilizing the aforementioned access system 10 will now bedescribed. Access system 10 can be used in a variety of procedures,although only one (1) exemplary procedure is described. For instance,access system 10 can be utilized in virtually all surgical approachesand in all areas of the spine. In addition, it is contemplated thataccess portal 40, adaptor 70, and viewing device 100 can be utilizedwithout certain aspects of access system 10 (e.g., without fixation pins22, 24), and along a variety of different approaches. For instance, itis contemplated that access portal 40, adaptor 70, and viewing device100 may be utilized by themselves and in surgical procedures conductedon a posterior approach (e.g., posterior lumbar interbody fusion (PLIF),transforaminal lumbar interbody fusion (TLIF), or similar proceduresconducted in the cervical or other regions of the spine), surgicalprocedures conducted on a lateral approach, and/or surgical proceduresconducted on an anterior or anterolateral approach (e.g., anteriorlumbar interbody fusion or oblique lumbar interbody fusion). Put simply,access portal 40, adaptor 70, and viewing device 100 are configured fora vast variety of surgical procedures, and it is to be understood that,while only one (1) type of surgery is set forth below, others can beperformed.

In one embodiment, a surgeon makes an incision in a patient's back andoptionally inserts a guide wire through the incision and into contactwith bone. Tissue dilators (not shown) are then inserted over the guidewire to sequentially dilate the patient's skin and tissue andatraumatically provide access to the surgical site. The tissue dilatorsmay include tapered distal ends and internal bores that successivelyincrease from one dilator to the next. In addition, the dilators mayhave different lengths, such that the dilator with the smallest internalbore has the longest length and the dilator with the largest internalbore has the shortest length.

To sequentially dilate the skin and tissue of the patient through theinitial incision in the patient's back, the surgeon can insert a firstdilator having a particular length and internal bore size into theincision and over the guide wire (if used), insert a second dilatorhaving a somewhat larger internal bore and shorter length over the firstdilator, and so on and so forth until an appropriate access path isestablished through the skin and tissue of the patient. The dilators maybe inserted into the incision along a direction that intersects with anintervertebral space 20 of adjacent vertebrae 21, 25 (e.g., along apurely posterior approach, a transforaminal approach, etc.), which canbe verified using standard imaging techniques, such as fluoroscopy. As afinal step, the surgeon may insert access portal 40 over the lastinserted dilator and then remove each of the utilized dilators out ofworking channel 56 of access portal 40 so that a minimally-invasiveaccess path is established through the skin and tissue of the patientand to a position adjacent intervertebral disc space 20. Depending onthe particular approach utilized (e.g., PLIF/TLIF), additional steps maybe required, such as resection of vertebral bone and/or a laminectomy,to establish effective access to intervertebral disc space 20. Thesesteps are set forth in detail in various surgical techniques publishedby the applicant (Stryker, Inc.) such as, for example, the publicationtitled “AVS™ TL Peek Spacer System: Surgical Technique,” published in2005 and provided with literature number IBATLST2B, the disclosure ofwhich is incorporated by reference herein.

When utilizing a pedicle-based retractor, such as that shown with accesssystem 10, the surgeon also makes separate incisions in the patient'sback to allow for insertion of anchoring pins 22, 24 into bone. Inparticular, anchoring pins 22, 24 may be cannulated and the surgeon maymake an incision in the patient's back, insert a guide wire (e.g., aK-wire) through the incision and into contact with the patient'spedicle, and then insert either pin 22, 24 over the K-wire and throughthe incision. This can also be done for the other pin 22, 24. With bothpins 22, 24 in place and in contact with bone (e.g., the patient'spedicle), arms 30, 32 and the remainder of frame 26 of the pedicle-basedretractor are attached to anchoring pins 22, 24. In addition, a clamp isattached to access portal 40 to stabilize portal 40 within the patient.In this condition, anchoring pins 22, 24 may be moved away from oneanother by way of sliding arm 30 along bar 34. Arm 30 may be fixed inposition once it is moved to a desired location. Moving arms 30, 32 awayfrom one another causes vertebrae 21, 25 to be distracted away from eachother so that intervertebral disc space 20 is decompressed. The surgeonmay then perform a variety of surgical procedures through access portal40, such as a standard discectomy (e.g., removal of intervertebral discmaterial in intervertebral disc space 20) and/or a fusion procedure. Avariety of surgical instruments may be inserted through working channel56 of access portal 40, either separately or simultaneously with oneanother, to perform such a discectomy and/or fusion procedure; and,during the procedure, endoscopic viewing device 100 may be utilized toprovide clear visualization of the working area inside the patient(e.g., intervertebral disc space 20).

With access portal 40 in place inside a patient, as set forth above, thesurgeon may then attach scope adaptor 70 to access portal 40 in themanner set forth in previous sections. Indeed, as shown in FIGS. 3A-C,projections 74 of adaptor 70 are aligned with spaced-apart openings 52through flange 46 of access portal 40, projections 74 are moved throughspaced-apart openings 52, and then adaptor 70 is rotated in the mannershown in FIG. 3B to secure adaptor 70 and projections 74 within channel50 between flanges 46, 48. The surgeon then inserts mounting section 102of endoscopic viewing device 100 through scope aperture 80 of adaptor 70so that the geometry of mounting section 102 mates with the geometry ofscope aperture 80. In this orientation, the surgeon can selectively moveviewing device 100 vertically up and down to move lens 106 vertically upand down. Lens 106 is then secured in a particular position by way ofscrew 86 (FIGS. 3B and 4B). And, adaptor 70 may also be rotated by thesurgeon circumferentially about proximal section 44 of access portal 40,thereby causing scope holder 78 and viewing device 100 to rotate aboutaccess portal 40, at which point adaptor 70 can be secured in arotationally-fixed position through the use of screw 82 (FIG. 4C). Asurgeon is thusly provided with a variety of options for positioningviewing device 100 to gain the best visualization of the working area atthe surgical site (e.g., intervertebral disc space 20).

After the surgeon performs a standard discectomy and/or other procedureunder endoscopic visualization from viewing device 100, which can beadjusted in any manner to achieve clear visualization as set forthabove, the surgeon may insert an interbody device into the at leastpartially excised disc space 20. The interbody device may be anexpandable implant, such as that shown in U.S. Ser. Nos. 13/587,205and/or 61/775,909, each of which is incorporated by reference herein, orit may be a non-expandable implant. In the case of a PLIF or TLIFprocedure, an implant can be inserted unilaterally, or multiple implantsmay be inserted into disc space 20 to bilaterally support adjacentvertebrae 21, 25. An example of an implant(s) usable in such a procedureis discussed in the publication “AVS™ TL Peek Spacer System: SurgicalTechnique,” incorporated by reference above. The implant or implantsinserted into disc space 20 may also be packed with bone graft or othersynthetic bone-growth materials to assist with achieving fusion ofadjacent vertebrae 21, 25 (e.g., for alleviation of pain caused by adefect with the patient's spine). Posterior stabilization devices (e.g.,rod fixation and/or other stabilizers) may also be used in connectionwith the insertion of such implants to stabilize the fusion procedure.

Access system 10, and in particular scope adaptor 70, access portal 40,and viewing device 100, therefore provides a system that effectivelyallows for improved visualization of the working area at the surgicalsite. The system is versatile, as set forth above, and allows thesurgeon many options for altering visualization of the surgical space,and for utilizing different tools (e.g., different scopes) during theprocedure.

In the devices shown in the figures, particular structures are shown asbeing adapted for use in an endoscopic viewing system. The invention(s)also contemplates the use of any alternative structures for suchpurposes, including structures having different lengths, shapes, and/orconfigurations. As an example, although access system 10 is in the formof a pedicle-based retraction system, other access systems may be usedthat do not attach to bone. For instance, access portal 40 may by itselfbe attached to a table arm or other supporting device to provide accessthrough the skin and tissue of a patient (e.g., during spinal surgery),without the use of fixation pins 22, 24. Thus, while fixation pins 22,24 are shown in connection with access system 10, such are not requiredand may be omitted in favor of alternate access systems that do notutilize those structures.

It is also contemplated that alternate viewing devices may be used, suchas rigid endoscopes or flexible, steerable endoscopes. For instance,since viewing device 100 is only provisionally attached to adaptor 70via screw 86, a surgeon may opt to remove viewing device 100 (which maybe a rigid scope) for another viewing device that is flexible andsteerable. Indeed, the surgeon may simply unscrew screw 86 and removeviewing device 100 vertically out of scope aperture 80 in exchange foranother viewing device. In this scenario, the surgeon may use theflexible, steerable endoscope to, for example, visualize surgical spacesbeyond the distal end of access portal 40. Since these types ofendoscopes are typically pliable adjacent at least their distal end, thesurgeon may visualize spaces beyond access portal 40 and navigate aroundbody structures by manipulating the flexible portion of the scope.

As another example, although adaptor 70 is described as being used onlyfor viewing device 100 above, adaptor 70 may include openings ormounting sections for other instrumentation, such as lighting. Indeed,an additional opening besides scope aperture 80 may be provided withadaptor 70 to allow for mounting of lighting instrumentation, whichcould extend into working channel 56 of access portal 40. Such lightinginstrumentation could also be movable vertically as well as rotatablecircumferentially about access portal 40, in a similar vein to viewingdevice 100. Alternatively, it is equally contemplated that otheradaptors, which are substantially similar to adaptor 70, may be providedfor mounting the aforementioned additional instrumentation (e.g.,lighting components). To use such adaptors, adaptor 70 may merely beremoved from access portal 40 in the manner set forth above, and thealternate adaptor may be attached to access portal 40 and used tosupport instrumentation such as lighting components, etc.

Further, while scope aperture 80 has been described as being offset froma center of working channel 56 of access portal 40, it is contemplatedthat scope aperture 80 (and thus viewing device 100) can be positionedat the center of working channel 56. In one embodiment, scope holder 78may be translatable for this purpose (i.e., for moving the location ofscope aperture 80 and thus viewing device 100 relative to the center ofworking channel 56). Stated differently, it is contemplated that scopeholder 78 may be longitudinally translatable towards and/or away fromthe center of working channel 56 (for example, through a telescopingarrangement) so that the position of scope aperture 80, and thus viewingdevice 100, could be moved. In this embodiment, scope holder 78 would befixable in position to fix the location of scope aperture 80 and viewingdevice 100.

Also, viewing device 100 may be rotatable within scope aperture 80,although that is not the case in the design of the figures due to theoblong shape of aperture 80 and mounting section 102 of viewing device100. To provide a rotatable viewing device 100, mounting section 102 andscope aperture 80 may be another geometry, such as circular orhexagonal. Alternatively, mounting section 102 of viewing device 100 maysimply be smaller in size than scope aperture 80, allowing rotation ofviewing device 100 within aperture 80. In such an embodiment, viewingdevice 100 may be rotationally-fixed within aperture 80 via screw 86 orthrough other compressive means.

Other structures besides screw 82 may be utilized to fix adaptor 70 inposition relative to access portal 40. For instance, a quick-releasemechanism may be utilized. Such a mechanism might comprise an adaptor 70that is separated or spaced apart at one section (e.g., semi-circular),allowing adaptor 70 to flex outwardly or inwardly. A connector may alsobe attached to opposite sections of adaptor 70 at the separation, theconnector being configured to draw the opposite sections of adaptor 70towards one another to compress adaptor 70 against access portal 40.Indeed, in some cases the connector may be a trigger that, when rotatedto an orientation in which it is alongside mating section 72 of adaptor70, causes the opposite sections of adaptor 70 to move toward oneanother thereby compressing adaptor 70 about access portal 40. In thisway, friction between adaptor 70 and access portal 40 may fix adaptor 70rotationally relative to access portal 40. Such a quick-releasemechanism may provide an easy way for a surgeon to change theorientation of viewing device 100 and re-fix adaptor 70 relative toaccess portal 40 after the adjustment. Other fixation mechanisms beyondthose set forth above may also be utilized, of course.

Although screw 86 is used to vertically fix viewing device 100, analternate fixation device may be utilized, of course. As an example, abutton/spring mechanism may be provided that is compressible withinopening 88 to secure viewing device 100 in a desired position. In suchan instance, a surface of the button, like screw 86, may contactmounting section 102 of viewing device 100 to provide compressionagainst mounting section 102 and secure viewing device 100 verticallywithin scope aperture 80.

In addition, although a single screw 82, 86 is shown in the figures, itis contemplated that multiple screws 82, 86 may be utilized. This isalso true of the alternate fixation structures noted immediately above(e.g., quick release mechanism and/or a compressible button).

Although the invention(s) herein has been described with reference toparticular embodiments, it is to be understood that these embodimentsare merely illustrative of the principles and applications of thepresent invention(s). It is therefore to be understood that numerousmodifications may be made to the illustrative embodiments and that otherarrangements may be devised without departing from the spirit and scopeof the present invention(s) as defined by the appended claims.

It will also be appreciated that the various dependent claims and thefeatures set forth therein can be combined in different ways thanpresented in the initial claims. It will also be appreciated that thefeatures described in connection with individual embodiments may beshared with others of the described embodiments.

The invention claimed is:
 1. A method of viewing a surgical site withina patient comprising the steps of: placing an access portal inside apatient, the access portal defining a working channel, the workingchannel having a distal end with a circular cross-section; securing aviewing device to the access portal; and rotating the viewing deviceabout a central axis of the access portal to position the viewing deviceto view the surgical site, wherein the step of placing the access portalincludes the step of mating an adaptor having at least one projectioncorresponding to at least one opening in the access portal.
 2. Themethod of claim 1, wherein the step of mating the adaptor to the accessportal including the step of placing the at least one projection of theadaptor in the at least one opening of a first flange of the accessportal, wherein the access portal include the first and a second flangespaced apart from one another to define a channel.
 3. The method ofclaim 2, further including the step of moving the at least oneprojection of the adaptor within the channel between the first andsecond flanges of the access portal to rotate the adaptor about thecentral axis of the working channel.
 4. The method of claim 3, furtherincluding the step of preventing disassociation between the adaptor andthe access portal by rotating the adaptor to a first orientation whereina portion of the first flange of the access portal overlies the at leastone projection of the adaptor.
 5. The method of claim 1, wherein thestep of securing a viewing device to the access portal includes a stepplacing a mounting portion of the viewing device in a first aperture ofa holder of the adaptor, wherein the holder extends proximally above aproximal end of the access portal and includes a first aperture with anaxis that is aligned with the working channel of the access portal, thefirst aperture being configured to receive the mounting portion of theviewing device.
 6. The method of claim 5, further including the step ofrotating and securing the viewing device to a desired position byrotating the adaptor to position the viewing device to the desiredposition and securing the viewing device in the desired position bysecuring the adaptor by a third fixation member, wherein the adaptorincludes a third aperture and the third fixation member movable withinthe third aperture, the third fixation member being configured to movewithin the third aperture to rotationally fix the adaptor relative tothe access portal such that the adaptor is selectively rotatable aboutthe central axis of the access portal.
 7. The method of claim 1, whereinthe viewing device is detachably connected to a holder of the adaptor.8. The method of claim 1, wherein the surgical site is a spinal site. 9.A method of viewing a spinal site during a surgical procedure using anaccess system comprising the steps of: dilating a patient's skin andtissue with one or more dilators to create an access path to a spinalsite; placing an access portal of the access system over the one or moredilators, the access portal defining a working channel with a centralaxis and having at least one opening, the working channel having distalend with a circular cross-section, wherein the distal end contacts afirst and second vertebrae such that a central longitudinal axis of theworking channel extends between the first and second vertebrae; securinga viewing device to the access portal; and rotating the viewing deviceabout a central axis of the access portal to position the viewing deviceto view the spinal site, wherein the step of placing the access portalincludes the step of mating an adaptor having at least one projectioncorresponding to at least one opening in the access portal.
 10. Themethod of claim 9, wherein the step of mating the adaptor to the accessportal including the step of placing the at least one projection of theadaptor in the at least one opening of a first flange of the accessportal, wherein the access portal include the first and a second flangespaced apart from one another to define a channel.
 11. The method ofclaim 9, wherein the step of securing a viewing device to the accessportal includes a step placing a mounting portion of the viewing devicein a first aperture of a holder of the adaptor, wherein the holderextends proximally above a proximal end of the access portal andincludes a first aperture with an axis that is aligned with the workingchannel of the access portal, the first aperture being configured toreceive the mounting portion of the viewing device.
 12. The method ofclaim 9, wherein the step of placing the access portal of the accesssystem over the one or more dilators includes the step of securing atleast one anchoring element to the first or the second vertebra, theanchoring element extending from the access system.
 13. The method ofclaim 12, further including the step of securing first and a secondanchoring elements to the first and second vertebrae respectively.